SOCIAL DETERMINANTS OF HEALTH in HIV/AIDS RESEARCH

Dr. John Cairney McMaster Family Medicine Professor of Child Health ResearchSenior Scientist, Centre for Addiction & Mental Health

OVERVIEW

(1) Overview of the population health & social determinants perspective

(2) Brief survey of the field & previous research

(3) Social justice – HIV/AIDS

POPULATION HEALTH

Focuses on the health of an entire population, rather than on individuals

Involves consideration of a very broad range of factors, including economic and social forces

Focus on intervention is populations, not individuals

INFLUENCES ON HEALTH

INFLUENCES ON HEALTH

Income and wealth: Absolute and relative deprivation

Social status: Education, occupational prestige

Social support Education: Influence

on behaviour Employment and

working conditions Physical

environment: air and water quality, housing, community safety

Biology and genetics

Health behaviours and practices

Child Development: Prenatal and early childhood experiences

Health Services: Availability and use of preventive and primary health care services)

From: Hamilton and Bhatti, Public Health Agency of Canada (http://www.phac-aspc.gc.ca/ph-sp/phdd/php/php.htm)

POPULATION HEALTH

Collective health Influenced by everything that affects an

individual’s health Some influences are difficult to trace at

the individual level but are very important to the population as a whole

Social determinants of health and biopsychosocial model of health

SOCIAL DETERMINANTS PERSPECTIVE CORE ASSUMPTIONS:

Virtually every aspect of life is determined by the place people occupy in the social order (Mills, 1959; Pearlin, 1989; 1999)

An individual’s location in the social structure has an important influence on their health & well-being

SOCIAL DETERMINANTS PERSPECTIVEWhat is social location? Usual suspects:

Gender Socioeconomic status (income, education,

occupation) Ethnicity Marital Status Age

Others? Gender identity Housing status Employment status

PREVIOUS RESEARCH

Decades of research confirm that social location is a powerful determinant of mental health, physical health, and mortality (Black Report, 1980; Link and Phelan, 1995; Wilkinson, 2003)

True at all stages of life (Cairney and Krause, 2005)

PREVIOUS RESEARCH

There is a SES gradient in health outcomes: As social advantages (wealth, status) accrue, health improves. Like rungs on a ladder, health is better at each successive level.

Material (Lynch) versus psychosocial explanations (Kawachi)

Pervasive association, detectable at different levels of social organization (e.g., Whitehall studies to Wilkinson’s work on Nation-states)

PREVIOUS RESEARCH

Income gradient in mood disorder in Canadians ages 15 and over. Source: CCHS 1.2

PREVIOUS RESEARCH

Interpretive Issues – Social Causation versus Social Selection Does low social or economic status

cause disorder (social causation)…

Or, does disorder cause low social or economic status (social selection)?

SOCIAL CAUSATION AND SELECTION: EITHER/OR? Social causation and social selection

are not mutually exclusive processes Current research often assumes that

both are operative Focus is on measuring relative

importance of selection and causation for specific outcomes and exploring the mechanisms through which they operate

Link & Phelan (2005) Distal versus proximal risk factor Social conditions are “distal” - therefore,

fundamental Why? Start with the “persistence” in SES

relationships over time Proximal risk factors have changed (poor

sanitation) – fundamental causes remain – position in the social structure conditions exposure

Link & Phelan (2005)

Why do social conditions remain constant, but proximal risk factors change?

“new mechanisms arise because persons higher in socioeconomic status enjoy a wide range of resources including money, knowledge, prestige, power, and beneficial social connections that they can utilize to their health advantage (Link and Phelan 1995)”

Social Policy Implications “First, social inequality produces health

inequality, and thus policies that reduce social and economic inequality will reduce health inequality.”

“Second, policies that benefit people irrespective of individual resources or initiative (for example, fluoridating water versus brushing with fluoride toothpaste) will be more effective in reducing health disparities than policies that require individuals to marshal resources to obtain health benefits.”

Social Policy Implications

“Third, we hold that policies that attend to the social distribution of knowledge about risk and protective factors— and the ability to act on that knowledge—are essential.

SOCIAL CAUSATION

A conceptual framework for understanding social inequalities in health and aging (from: House, 2001)

SOCIAL CAUSATION & SELECTION

Biological Factors, Social Conditions in the Context of Life Course Development:

“Specific genes are known to alter the likelihood of specific behaviors. For example, a gene might be associated with the likelihood to engage in impulsive behaviors. Clearly, a totally impulsive person would function poorly in most modern social settings … But genetic influences on behaviors like impulsivity depend on social circumstances. Imagine two people who have an equally high genetic propensity for impulsive behavior. Yet perhaps one person grows up in a permissive family and the other person grows up in an authoritative family. These two people may well differ in their levels of impulsive behavior and, ultimately, how well they function in adult settings. Of course, life is more than family;  the difficulty is capturing the multidimensional,  temporal complexities of people’s experiences.”

~ Michael Shanahan, UNC Sociology

Health People 2010 Report: US Department of Health and Human Services, 2000.

Gene – Environment Interactions

Relatively new model for child health & development

Diathesis-stress model: the right environmental stressor triggers genetic vulnerability

Another way of explaining why some children are affected by environment, others not

Maltreatment (Abuse) and Conduct Disorder

Conduct disorder – antecedent to anti-social personality disorder

Abuse is a risk factor – especially in boys Genetic component – violent behaviour Interaction?

Source: Jaffee et al. (2005) Developmental and PsychopathologyDevelopmental and Psychopathology

INTERLOCKING SYSTEMS APPROACH Typical approach: Examine outcomes by income

or sex or ethnicity and controls for other “risk factors” E.g., is female sex a risk factor for depression

independent of SES, ethnicity, etc.”? Sex, SES, ethnicity, etc., all influence social

location and access to resources… …but also combine to produce complex social

roles that cannot be treated as simply the sum of their parts

Multiple-jeopardy hypothesis

HEALTH AS A SOCIAL JUSTICE ISSUE

HIV/AIDS as a special case Social inclusion/exclusion OHTN Cohort Study

DEVELOPING A POPULATION HEALTH PROMOTION MODEL

Hamilton and Bhatti, Public Health Agency of Canada (http://www.phac-aspc.gc.ca/ph-sp/phdd/php/php.htm)